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OiHOINAL STATE OK CAUPORNIA Da riot fiU in <br /> '1'He RESOURCES AGENCY pp�� 197611e, <br /> FfIO w" aWR <br /> DEPARTMENT OF WATER RESOURCES IVO, <br /> WATER WELL DRMLERS REPORT state well N,D 11�fl,�ok t �4Zi 0A <br /> Los It Ma or Dste Other Well Ito w <br /> t <br /> (i) 0VME�i11. iv c( (I2) WELL LOG: Total�tb_�-__ � nem,►aE tea�el��r <br /> Add., fmm ft to EL Formation (Desenbe by calor, character, we ar materiel) <br />' Cat! 91J� w <br /> I—P-c- <br /> (2) L CATION OF (seeinsUmebans). 2 <br /> County vnee.Well Plumber � <br /> %V ell arkhow if different ftam 4^5;x, <br /> - <br />' T.—hin- L &I p`--"gn, tG% <br /> Vi"noa from cit>Q,salo6 mitmads,fences,etc. - ��` ♦� AQ +�U1a�r f � w(� <br /> +r G�.lt4� �Ca x171 <br /> (3) TYPE OF WORK: <br />' Nets W Ay 17eepeawc Q iJ-S\ _ <br /> Ademtstmctfea a - 3 6 m �'M1,t 0 IR ally? <br /> E ?► neva ere - 3C ut— <br /> Horitoaml wolf C - _i- ,. <br />' !j+ Darstr4ctloa Q IDescriha �� (R?&1 Q 1N-046{,}!9'f 09Af <br /> fL t j 4 � �i��' s� •" �l(1 2Y? �1N��'IGf�G <br /> Dam>� ti <br /> lndnetxial ❑ �13 <br /> T. W IL <br /> 1 � s <br /> �1 1 <br /> Nva. .ocATION S7ETCH <br /> (53 Egufr-MILNT+ (a) G"TEkINVAcx. - <br /> Ratarr Reverse ❑ <br /> Cable i7 AW Q of t - <br /> C1s�er © Sucker [] am \\ ) - <br /> 1 (1) CALSiID4G INSTALXM:)-x I8) EliltgSL►�IO s ti - <br /> Sted Q PUS&Q Ca( Typo aE per t"or]fits of aereea {�1 <br /> Fknsn Tor" Diaof <br /> ss F <br /> To <br /> a. G <br /> ft. ft t � la. tiYal1 it. - <br /> • — <br /> tALIAa <br />' (9) WELL SEAL; �v M..Ca9�-,-Pln <br /> Was surface ssnihrry anal pmvsdad? Yd Mo Q it Yes, to devih_____«ft- <br /> were scram sealed �aga-i�asrt nollrsefara? XeS No (] - <br /> Stethod of stalfa T.�� Work va <br /> (10) WATER T LV f s o WELL DRILIZ S STATEMENT. <br /> Depth of first waw, if Thar ++m <br /> won drilred under V fusix$ n atloand thre resort is tree to the ban of my <br /> Stmt level after wd1 carople L krsorOWPA �/ lL>CJ <br />' (11) WELL TESTSr S <br /> Was well test made? yew%t3 No❑ if yes,by wham 11 t-17 (Well t]rlller) <br /> Time of tart PUMPHader 0 Alr trft ❑ NAbi -4 kJILL, <br /> f)osrrh to water at start mi Mst h At and of fast it (>' RrMo.or on) (Type Prlaeed) <br /> DlsebarX ■l/vena after hafts Yater tam .lddreS <br />' c . III <br /> aalra5s made? T-)4 X-(3 If Yes.11 wlsom7`/ <br /> do Ina made? Yes Ka(3 If yet.attache to th>a ixr(stsrt Licema Na -Date M thrs OR 168 (treV 'r 761 IF ADDITIONAL SPACE 15 NEIS13F-0. USE NEXT CONSECUTIVELY NUMBERED FORM <br />